Constipation

Constipation is not a disease but rather a series of symptoms caused by a number of different factors. Defining constipation is not an easy task, since the frequency of normal bowel defecations differs from person to person.

Generally, we talk about constipation when the frequency of bowel defecations is less than 2-3 times per week or when they take place with great difficulty and are accompanied with pain and exhaustion.

Constipated patients* are those who do not use laxatives and report at least two of the following symptoms, fulfilled for the last 3 months with symptom onset at least 6 months prior to diagnosis:

• less than 3 bowel  defecations per week
• hard or lumpy stools  in at least 25% of defecations
• sensation of incomplete evacuation in at least 25% of defecations
• sensation of anorectal obstruction /blockage for at least 25% of defecations
• manual manoeuvers necessary to facilitate defecation in at least 25% of defecations

There are two main types of constipation: occasional (e.g. due to changes in diet, stress, lifestyle changes, frequent travelling) and chronic (e.g. due to a certain illness or medication use).

*Rome III Diagnostic Criteria for Functional Gastrointestinal Disorders

Constipation may be due to several different causes. The most common ones include:

• Diet habit changes
• Pregnancy
• Limited physical activity
• Insufficient intake of fluids & fibres
• Use of medication, such as certain: painkillers (especially opioids), antacids (containing aluminium or calcium), hypertension medications (calcium antagonists), iron supplements, diuretics, anticonvulsants, antidepressants, antiparkinsonian agents, antiepileptics etc.
• Polypharmacy, especially in the elderly
• Laxative abuse
• Stress – psychological causes
• Known pathogenic conditions causing constipation, such as irritable bowel syndrome (spastic colitis) & other colon conditions, certain neurological diseases (multiple sclerosis, Parkinson’s disease), metabolic & endocrine disorders (diabetes mellitus, hyperthyroidism, hypercalcemia, hypokalemia) etc.
• Traveling & lack of proper hygiene conditions
• Chronic constipation history
• Recent surgery in the perianal area or in the perineum
• Infancy and childhood
• Individuals over 55 years.

Older people have increased chances of experiencing constipation in comparison to younger aged. This is usually due to dietary factors, lack of physical exercise, medication intake, as well as due to reduced bowel motility because of aging.

In most cases, changes in diet and lifestyle help relieve the symptoms and prevent constipation.

Some useful tips:

• Try to exercise daily. For instance, try to find some time for daily walking as it facilitates defecation especially if it takes place before visiting the toilet. Should you work in an office, try to take frequently breaks.
• Follow a balanced diet, rich in natural fibers like rusks and whole grain cereals (i.e. wheat, oat etc.), fruits (i.e. figs, kiwis, pears, peaches, plums etc.), vegetables (i.e. green beans, okras, wild greens in winter etc.) & legumes.
• Eat dried fruits like plums & apricots.
• Drink plenty of fluids (at least 1,5lt daily), mainly water.
• Do not ignore the urge to have a bowel evacuation. Try to schedule a daily, regular and specific time to have a bowel defecation.
• Significant changes in stool quality and bowel evacuations should be reported to your attending physician.

When the above changes of habits do not produce results, the attending physician will look for the cause of the problem and recommend a method of treatment, selecting the most appropriate medication, which may include laxatives.

Laxatives, depending on their mechanism of action, are classified** into four categories: bulk-forming laxatives, stool softeners, osmotic laxatives and stimulant laxatives.

1. Bulk-forming laxatives: These include different types of natural polysaccharides, such as wheat bran, hydrophilic colloids from certain plant seeds (psyllium) or synthetic polysaccharides (methyl cellulose) acting in the small and large intestine. They are considered more “innocuous”, because they promote intestinal peristalsis (motility) owing to their increased volume (they absorb water, forming bulkier, soft stools, and increase the motility of the intestinal muscles). They are marketed in combination with laxatives from the other categories.
2. Stool softeners:  This category mainly includes paraffin or paraffin liquid (mineral oil), a complex mix of saturated, petroleum-based hydrocarbons. These laxatives coat stools, making them more slippery and easy to pass. They are mostly used by people suffering from hemorrhoids or other painful conditions of the rectal area.
3. Osmotic laxatives: Magnesium salts, different tartrate salts, some semi-synthetic polysaccharides (lactulose and lactitol), polyethylene glycols (macrogols) and glycerin fall into this category. Osmotic laxatives act in a manner similar to bulk-forming laxatives, in the sense that they draw water into the colon to soften stools and increase their volume, making them easier to pass (acting like a sponge in water).
4. Stimulant laxatives: The laxatives of this category stimulate intestinal motility (meaning the contractions of the intestinal muscles), mainly of the large intestine, and decrease the absorption of water and electrolytes. Bisacodyl, castor oil, senna and sodium picosulphate are included in this category.

** Laxative categories according to the Anatomical Therapeutic Chemical Classification System (code A06), World Health Organization.